Patient-centered communication is a component of high-quality health care that foregrounds the patient’s orientation and experience during patient–provider interactions. Specifically, these medical interactions emphasize caring, trust, rapport building, shared decision making, and the social and emotional well-being of the patient (Mauksch, Dugdale, Dodson, & Epstein, 2008). In practice, effective communication between patients and their health providers involves and informs a number of actions consequential to short- and long-term health outcomes. These actions include shared medical decision making, facilitating positive patient activation and successful self-management of health conditions, helping patients to navigate complex health systems, managing uncertainty, and engaging in a meaningful information exchange (Epstein & Street, 2007; Maly, Stein, Umezawa, Leake, & Anglin, 2008; Ong, de Haes, Hoos, & Lammes, 1995). Studies affirm various pathways through which specific and well-defined communicative behaviors on the part of physicians directly and indirectly contribute to better health outcomes for patients (Street, Makoul, Arora, & Epstein, 2009). However, research suggests that, when interacting with physicians in general, African Americans report less satisfaction with patient–provider communication and less shared decision making when compared with white Americans (Maly et al., 2008; Manfredi, Kaiser, Matthews & Johnson, 2010; Peek et al., 2009). Furthermore, studies have reported that some primary care physicians hold negative perceptions of African American patients that affect their ability and willingness to engage in patient-centered communication and care, resulting in objectively different content, tone, and overall quality of communication with their African American versus white patients (Cooper et al., 2012; Johnson, Roter, Powe, & Cooper, 2004; Moore et al., 2012) and less time spent talking with African American patients (Cené, Roter, Carson, Miller, & Cooper, 2009). For instance, African American patients are often viewed as noncompliant, less-effective communicators, and less educated during medical encounters (Cooper & Roter, 2003; Moore et al., 2012). In line with these findings, studies show that some primary care physicians are more verbally dominant with African American patients than white patients; treat African American patients more contentiously; are less likely to use supportive talk; and misunderstand or misinterpret cultural values, beliefs, and relational needs that inform African American patients’ health decisions and behaviors (Hammond, 2010; Moore et al., 2012; Street, Gordon, & Haidet, 2007). These findings are particularly relevant for African American men who experience higher morbidity, poorer prognoses, and higher mortality across a range of chronic diseases (Thorpe et al., 2013). Multiple factors contribute to such disparities, and a lack of patient-centered patient–provider communication may play an important role. Specifically, when African American men perceive differential treatment attributed to their race during medical visits, they are distrustful of their physician and the health care system overall (Hammond, 2010), potentially leading to a reluctance to engage with the health care system for future needs and critical delays in the diagnosis and treatment of serious illnesses (Hammond, Matthews, Mohottige, Agyemang, & Corbie-Smith, 2010). Social workers can play a key role in facilitating higher-quality patient–provider communication for African American men (Gehlert, 2012; National Association of Social Workers [NASW], 2017). According to NASW, social workers in health care settings offer a range of services aligned with strengthening the patient–provider relationship, including facilitating teamwork and collaboration, promoting quality improvement in health care processes, providing support with system navigation, soliciting the involvement of supportive networks, and advocating for a patient’s personal autonomy while working from a strengths-based perspective (NASW, 2017). Social workers are also trained to facilitate health behavior change, deliver individual and group psychosocial interventions that are consequential to health outcomes, help patients become more informed consumers of health care services, provide crisis intervention, and work within limited time and fiscal constraints to find medical or community-based accommodations for patients with complex health conditions, among a range of other skills (Mitchell, 2012). Prior research has often failed to consider how social workers in health care settings can uniquely support older adults and underserved racial and ethnic minority groups in improving the quality of patient–provider communication. In addition, research on African American men and their experiences with patient–provider communication remains limited. The current study highlights the sociodemographic variation among African American men who report experiencing suboptimal patient–provider communication with regard to one specific measure: feeling listened to during medical visits. We also consider the ways in which social workers embedded in clinical settings might serve as cultural brokers to facilitate improved health communication in support of African American male patients. Method Sample Between 2006 and 2010, a large hospital system in the Midwest conducted a demonstration project to examine whether a longitudinal patient navigation intervention could increase the utilization of cancer screening tests among older African American adults enrolled in Medicare (Parts A and B). This study was funded by the Centers for Medicare and Medicaid Services. The original study recruited a large sample of 5,783 African American adults age 60 and older from more than 25 senior residences, nearly 100 senior activity centers, and approximately 50 church groups within and closely representative of the catchment area of the health care system. Participants completed a baseline questionnaire that contained adapted items from existing instruments and measures assessing mental and physical health history and status, access to and perceptions of health care, health behaviors and beliefs, and demographic items. A trained research assistant or nurse collected the baseline data by phone or in person. The current study obtained the deidentified data for all African American men in the original study (n = 1,666), with the approval of institutional review boards of both the parent hospital and the affiliated university, to conduct a secondary analysis focused on their responses to items referencing health communication. Data underlying the findings described here are not yet publicly available, and additional details about this study and findings from this sample are published elsewhere (Mitchell, Manning, Shires, Chapman, & Burnett, 2015; Mitchell, Watkins, Shires, Chapman, & Burnett, 2017) Measures Outcome Variable A single item measured patient–provider communication. Participants were asked, “In the past 12 months how often did you feel your doctors or other health care professionals listened carefully to you?” This variable was coded as 0 for always/usually/sometimes and 1 for never. Independent Variables Independent variables found in studies to be related to patient physician communication and included here were age, education, income, marital status, self-care, pain/discomfort, emotional well-being, and trouble with mobility. Age was coded as 0 for under 75 years and 1 for 75 years and older. Education was categorized as high school or less (0) or some college or more (1). Income was coded as 0 for greater than $20,000 per year and 1 for less than or equal to $20,000 per year. Marital status was categorized as single (0); widowed, divorced, or separated (1); and married or partnered (2). Self-care and pain/discomfort were measured by asking participants to indicate which statement best described their own health state today: Self-care was coded as 0 for “I have no problems with self-care” and 1 for “I have some problems washing or dressing myself” or “I am unable to wash or dress myself.” Pain/discomfort was coded as 0 for “I have no pain or discomfort” and 1 for “I have moderate or extreme pain or discomfort.” Emotional well-being was measured by asking, “How much of the time during the past four weeks have you felt downhearted and blue?” and coded as 0 for none of the time and 1 for most of the time. Last, trouble with mobility was measured by asking participants, “For each moderate activity, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf, how limited are you in performing the activity?” and was coded as 0 for not limited at all and 1 for limited moderate activity. Analysis For descriptive analysis, frequencies were calculated for all variables. Key independent variables were cross-tabulated with the outcome (patient–provider communication), and differences across groups were calculated using t tests for continuous variables and Pearson’s chi-square tests for categorical variables. A logistic regression model was used to examine the association between predictors and patient–provider communication. Logistic regression was used for patient–provider communication because the measure was dichotomous. Analyses were conducted using SPSS (Version 22), and a missing value analysis determined that missing values were randomly distributed across all cases such that no individual variable had more than 20 percent of missing cases. Results Demographic and other characteristics for the analytic sample for African American men who reported problems and those who did not report problems with patient–provider communication are presented in Table 1. A majority of African American men who reported that their physician never listened to them in the last 12 months were under the age of 75 (51%); earned more than $20 K (70%); and were more likely to be widowed, separated, or divorced (52%). In addition, 70% of men in this category reported their highest level of education as high school or less. A majority of men who perceived that their physicians did not listen to them also reported no problems with self-care (91%), experienced no pain (53%), were more likely to be downhearted (79%), and had no trouble with mobility (69%). Table 1: Main Variable Comparisons, by Patient–Physician Communication (N = 1,666) Variable Doctor Never Listens (n = 1,336) n (%) Doctor Always/Usually/ Sometimes Listens (n = 330) n (%) p Education .03 High school or less 938 (70) 214 (65) Some college or more 396 (30) 116 (35) Age .00 Under 75 682 (51) 214 (65) 75 and older 654 (49) 116 (35) Annual income ($) .00 Greater than 20,000 931 (70) 180 (55) 20,000 or less 405 (30) 150 (45) Marital status .00 Single 149 (11) 52 (16) Widowed/separated/divorced 700 (52) 101 (31) Married/partnered 486 (36) 167 (52) Self-care .01 No problems with self-care 1,219 (91) 287 (87) Some problems/unable to care for self 117 (9) 43 (13) Pain/discomfort .00 No pain 705 (53) 141 (43) Moderate/extreme pain or discomfort 631 (47) 189(57) Emotional well-being .00 Not downhearted/blue 281 (21) 138 (42) Downhearted/blue some/most of the time 1,055 (79) 192 (58) Trouble with mobility .00 Not limited at all 927 (69) 186 (56) Limited moderate activity 409 (31) 144 (44) Variable Doctor Never Listens (n = 1,336) n (%) Doctor Always/Usually/ Sometimes Listens (n = 330) n (%) p Education .03 High school or less 938 (70) 214 (65) Some college or more 396 (30) 116 (35) Age .00 Under 75 682 (51) 214 (65) 75 and older 654 (49) 116 (35) Annual income ($) .00 Greater than 20,000 931 (70) 180 (55) 20,000 or less 405 (30) 150 (45) Marital status .00 Single 149 (11) 52 (16) Widowed/separated/divorced 700 (52) 101 (31) Married/partnered 486 (36) 167 (52) Self-care .01 No problems with self-care 1,219 (91) 287 (87) Some problems/unable to care for self 117 (9) 43 (13) Pain/discomfort .00 No pain 705 (53) 141 (43) Moderate/extreme pain or discomfort 631 (47) 189(57) Emotional well-being .00 Not downhearted/blue 281 (21) 138 (42) Downhearted/blue some/most of the time 1,055 (79) 192 (58) Trouble with mobility .00 Not limited at all 927 (69) 186 (56) Limited moderate activity 409 (31) 144 (44) Using logistic regression, Table 2 shows odds ratios (ORs) and confidence intervals for a model predicting African American men’s likelihood of having a doctor who never listens. The model tested the role of sociodemographic and other factors relevant to patient–provider communication. In the present sample, African American men who were older than 75 years were more likely to report that their doctor never listens (OR = 1.540, p < .05). Men who were separated, widowed, or divorced (OR = 1.635, p < .05) and those who reported feeling downhearted or blue some or most of the time (OR = 2.143, p < .001) were also more likely to report problems with patient–provider communication. Men who reported limited moderate activity (OR = 0.603, p < .001) and those who had an income of less than $20,000 per year (OR = 0.745, p < .05) were less likely to encounter a doctor who they perceived as never listening to them. Table 2: Predictors of Having a Doctor Who Never Listens OR 95% CI Education High school or less Some college or morea 0.779 [0.594, 1.022] Age (years) Under 75a 75 and older 1.540** [1.170, 2.027] Annual income ($) 20,000 or less More than 20,000a 0.745** [0.561, 0.989] Marital status Single Married/partnereda 0.899 [0.616, 1.313] Separated/widowed/divorced 1.635** [1.078, 2.481] Self-care Not a problema Some problems/unable to care for self 1.052 [0.688, 1.610] Pain/discomfort No paina Moderate/extreme pain or discomfort 0.870 [0.6622, 1.142] Emotional well-being Not downhearted/bluea Downhearted/blue most of the time 2.143*** [1.631, 2.802] Trouble with mobility Not limited at alla Limited moderate activity 0.603*** [0.451, 0.807] OR 95% CI Education High school or less Some college or morea 0.779 [0.594, 1.022] Age (years) Under 75a 75 and older 1.540** [1.170, 2.027] Annual income ($) 20,000 or less More than 20,000a 0.745** [0.561, 0.989] Marital status Single Married/partnereda 0.899 [0.616, 1.313] Separated/widowed/divorced 1.635** [1.078, 2.481] Self-care Not a problema Some problems/unable to care for self 1.052 [0.688, 1.610] Pain/discomfort No paina Moderate/extreme pain or discomfort 0.870 [0.6622, 1.142] Emotional well-being Not downhearted/bluea Downhearted/blue most of the time 2.143*** [1.631, 2.802] Trouble with mobility Not limited at alla Limited moderate activity 0.603*** [0.451, 0.807] Notes: OR = odds ratio; CI = confidence interval. aReference category. *p < .10. **p < .05. ***p < .001. Discussion These results reflect one important dimension of the patient–physician relationship, feeling heard. If reflective of actual practice, our study raises the concern that certain sociodemographic subgroups among African American men may be afforded fewer opportunities to communicate their needs and concerns during already brief medical visits. In the current study, men who were age 75 or older, single, separated, widowed, or divorced, and men with depressive symptoms were the same participants who reported that their doctor never listened to them. African American men over age 75 were significantly more likely than younger men to report this issue with patient–provider communication. These findings are consistent with a body of literature documenting a range of barriers older adults may face to accessing high-quality patient-centered health care. For example, older adults may have difficulty due to a lack of reliable transportation, inadequate social support at home, trouble navigating an ever-changing and complex health care system, encountering health care professionals undereducated in geriatrics, and cultural barriers to care (Horton & Johnson, 2010). Our findings suggest a need for increased clinical attention to the specific and potentially unique communicative needs of older African American men. Marital status was also significant in predicting communication issues in this study, and older African American men may also benefit from increased research on how the presence of spouses or partners during medical interactions influences the quality and dynamic of patient–provider communication. In line with extant research (Mitchell et al., 2017; Watkins, Hawkins, & Mitchell, 2015), our findings suggest a link between mental and emotional health, and communication with a health provider in health care settings. In the current study, men who reported feeling downhearted or blue were more likely to report that their doctor did not listen to them. Literature documents that African American men may not identify with the label of depression, but instead use more culturally acceptable language for depressive symptoms, such as “downhearted” or “blue” (Mitchell et al., 2017). Research has also shown that health providers may often misidentify or misdiagnose depressive symptoms in African American male patients (Watkins, 2012; Watkins et al., 2015). Earlier work has shown that individuals who experience mental health issues, such as depression, are more likely to engage in poor adherence to medical regimens, experience worse health outcomes, and are more likely to report feeling disrespected by physicians in medical settings (Jonassaint et al., 2013); moreover, physicians are more likely to negatively rate and have lower levels of positive regard for patients who present with depressive symptoms (Jonassaint et al., 2013). Together, then, this research suggests that among older African American male patients, experiencing mental or emotional health issues may both compound and contribute to the effects of poor patient–provider communication. Research on the specific mechanisms through which mental and emotional health affect patient–provider communication is extremely limited for this population and in need of attention. Interestingly, men who had an income of less than $20,000 per year and men who had limited mobility were less likely to report having a doctor who never listens. We speculate that men with a lower income may have less access to health care and thus may have fewer interactions with physicians, in addition to being less informed about effective communication practices in patient–provider interactions. In addition, men with limited mobility may have more interactions with health care due to their physical conditions, which may increase their level of communication with providers. More research is needed to gain a deeper understanding of these findings. Role of Social Work in Health Care Communication Positive communication with providers can result in more active participation in medical care and improvement in perceived quality of communication by patients (Gourlay, Lewis, Preisser, Mitchell, & Sloane, 2010). Successful patient–provider communication can be achieved through the utilization of an interdisciplinary team of health care professionals (Gehlert, 2012; Peterson, 2012). Specifically, social workers are in a unique position to help improve the quality of communication between physicians and patients (Peterson, 2012). As our results indicate, clinicians working within integrated and community health settings might identify and provide additional support and resources for older, single African American men with higher incomes and those with depressive symptoms in an effort to facilitate higher quality doctor–patient communication. A review of interventions geared at treating older adults found that a team-based approach to health care provision in addition to enhanced communication between care providers across the continuum was essential for achieving optimal health outcomes for older adults (Hickman, Newton, Halcomb, Chang, & Davidson, 2007). Social workers are particularly well trained to identify and assess the needs of older African American men experiencing emotional issues, who may be at higher risk for having suboptimal medical interactions with physicians. Social work clinicians are critical gatekeepers who may be able to assess a patient’s understanding of and ability to navigate the health care system, connect them with resources, and work as a cultural broker to aid physicians and other health providers in understanding how age, culture, gender, and possible prior poor health care experiences may shape how individual patients respond to medical advice, express concerns, or involve family members in decision making. Social work clinicians in health care settings have a particularly important role in supporting the personal autonomy of older African American men and advocating that physicians empower them in medical decision-making processes. Research has shown that primary care providers are often more verbally dominant and engage in less patient-centered communication with African American patients than with white patients (Johnson et al., 2004) and may be less culturally competent regarding how African Americans perceive and manage health conditions (Street & Haidet, 2011). Social workers can help to inform health care providers of the importance of respecting and promoting the right of patients to self-determination, while assisting patients in their efforts to identify and communicate their own goals for their care. Additional studies that test the effectiveness of social work interventions for promoting improved patient–provider communication and patient’s active participation would support social work clinician’s increased involvement in this aspect of patient-centered care. Limitations and Conclusions A relatively large sample size was used for an otherwise understudied population. However, the baseline questionnaire analyzed for this study was cross-sectional and lacked random sampling, limiting the ability to infer causality or generalize these findings to other patient populations. Furthermore, due to the secondary nature of existing data, we were limited in our ability to use more comprehensive measures of patient–provider communication. Also, the geographic homogeneity of participants limited the ability to generalize findings to other populations. Future studies seeking to overcome such limitations might use a more representative longitudinal study with a more comprehensive set of validated patient–provider communication measures. Despite these limitations, this study has advanced the discussion on important determinants of patient–provider communication for a population experiencing marked health care disparities and provided a nuanced examination of older African American men’s experiences with this important aspect of health care. Furthermore, we advocate for social work’s increased role in engaging patients and providers around communication quality. This recommendation is tempered by the reality that not all social work clinicians are in a position to directly influence this dynamic. Undoubtedly, social work clinicians and researchers will be critical to improving the quality of patient-centered health care and communication for older African American men. Our hope is that this line of inquiry will move us one step closer. Jaclynn M. Hawkins, PhD, MSW, is assistant professor, School of Social Work, Michigan State University, 655 Auditorium Road, Baker Hall, Room 122, East Lansing, MI 48824; e-mail: firstname.lastname@example.org. Jamie Mitchell, PhD, MSW, is assistant professor, School of Social Work, University of Michigan, Ann Arbor. References Cené, C. W., Roter, D., Carson, K. A., Miller, E. R.III, & Cooper, L. A. ( 2009). 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Published: Mar 1, 2018
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